Internal Business Process Efficiency as a Driver of Financial Performance and Service Sustainability: A Balanced Scorecard Multi-Case Study of Indonesian Hospitals in the JKN Era

ABSTRACT: The implementation of Indonesia’s National Health Insurance (Jaminan Kesehatan Nasional/JKN) through the INA-CBGs prospective payment scheme has restructured hospital financial dynamics, with JKN revenue growing from 12.74% to 50.51% of total income while operating cost growth outpaces revenue growth, compressing operating profit. This study examines the internal business process efficiency strategy and its contribution to financial performance and service sustainability in three privately managed hospitals in East Kalimantan, Indonesia, using the Balanced Scorecard (BSC) internal business process perspective as the analytical framework. This article is part of a broader four-perspective BSC study; the full study integrates 16 strategic objectives and 41 KPIs. Employing a qualitative multi-case study design, data were collected through semi-structured interviews with 15 key informants and document review across RS X (Type C, 100 beds), RS Y (Type D, 60 beds), and RS Z (Type D Special, 38 beds). Thematic analysis identified four internal business process sub-themes: (1) digital innovation and system integration (SS9), (2) JKN claims management and pending mitigation (SS10), (3) clinical standard-based quality and cost control (SS11), and (4) governance and cross-unit collaboration (SS12)—supported by eight KPIs (I1–I8). Each hospital develops a distinct, contingency-shaped efficiency approach. The BSC strategy map demonstrates that these internal process improvements form a direct causal chain to financial outcomes: effective claims management reduces pending claim losses; clinical pathway compliance controls per-episode costs relative to INA-CBGs tariffs; and integrated systems accelerate revenue recovery. Findings affirm Contingency Theory and contribute a contextually grounded framework for hospital internal process governance under prospective payment systems.

KEYWORDS: Balanced Scorecard; Internal Business Process; Hospital Efficiency; JKN; INA-CBGs; Financial Performance; Service Sustainability; Qualitative Case Study